Famous Foot Fractures - Department of Radiology€¦ · Ankle Fx Classification: Weber B P,A 20yoM Intact Trans syndesmotic AO: Type B1 “Uni-Malleolar Fx” A,C 54yoF Syndes Intact

©Ken L Schreibman, PhD/MD 12/2/15 www.schreibman.info

page 1 of 12Famous Foot FracturesWeber, Lisfranc, & Jones

MortiseSyndesmosisFibula FxsWeber ABC

Ankle viewsFoot viewsLisfranc FxDeSt.Martin

5th MetatarsalAvulsion FxJones FxSir Robert

© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info

Famous Foot Fractures

1/52

To get a better understandingof 3 common

eponymic fractures

Weber@Ankle Joint

Lisfranc@T-MT Joint

Jones@5th MT

Ankle MortiseAnatomyFracture Patterns

T-MT JointFx/Disloc PatternsHow not to miss

5th MTAvulsion FractureJones Fracturec/o Ankle Pain

Goal Objectives

www.schreibman.info Ken Schreibman, PhD/MD Professor of RadiologyUniversity of Wisconsin – Madison






2/52

Ankle fractures are commonAnkle fxs = 10% of ALL extremity fxs4th most common extremity fx1st ?2nd?3rd ?

Bimodal Distribution

Rockw ood & Green’s Fractures in Adults8th Ed. ©2015 [Kindle Edition] Table 3-3*

…Distal Radius = 17%…Metacarpals = 11%…Proximal femur = 11%

Figure 3-3

Distal RadiusTibial shaft

AnkleM

F

Ankle fractures are increasingly common

Figure 59-1

Incidence of anklefractures inolder women

Kannus et al. Finnish statistics 1970- 2000 and projections for the future. Bone. 2002;31(3):430–433

*Roy al Infirmary Edinburgh 6,996 fx s/y ear

(19/day)






3/52

Ankle = Mortise & Tenon Joint

mr-d-n-t.co.uk/w ood-joints.htm

Mortise: “a hole or recess,receives a corresponding projection (Tenon)to lock the parts together”

One of the strongest joints

Stonehenge 3000 BCWikipedia

Tenon

Talus(Tenon)

Mortise

Mortise & Tenon joints are NOT supposed to move

Tibia

Fibula

Lintel






4/52

Other Joints have more Range Of Motion

To dow nload those and all of my lectureswww.schreibman.info

from Shoulder ImagingASRT@RSNA 2014

from Elbow ImagingASRT@RSNA 2013

ShoulderBall & Socket Joint 360° rotational ROMMost dislocated joint45% of ALL dislocations

Incidence:24/100Kperson-years

ElbowHinge JointGood ROM in 1 plane150° Flexion

Infrequently dislocates

Incidence:5/100k person-years(1/5th that of shoulder)JBJS Am. 2010

Mar;92(3):542-9 JBJS Am. 2012Feb 1;94(3):240-5






5/52

Ankle is really a Hinge JointRange of motion in essentially 1 planeDorsiflexion 15°Gait: Heel strike

Plantarflexion 55°Gait: Toe off

Limited rotational ROMHeel Inversion/Eversion

mostly at subtalar jointAnkle mortise provides

Stable platformRarely dislocates

in isolation Incidence 2/100K p-y

(<½ that of elbow)

Easily fracturedAnkle fxs=10% of ALL extremity fxs

BMC Musculoskelet Disord 2011 Nov 5;12:253

w ww.cdc.gov/ncbddd/jointrom/

SubtalarJointDorsi

Plantar






6/52

Ankle Mortise has Malleoli“Malleolus”[L] Little malletHave no tendon attachmentsHave ligament attachments

Tibia

Fibula

MedialMalleolusLateral

Malleolus

Coronal T2 FatSat

Deltoid LigFan-shaped

Talo-Fib LigAnt & Post

Talo-Fib

Deltoid

MM

LM

3 Malleoli

Anterior v iew

Medial v iewTibia

PosteriorMalleolusMM

Ant. Colliculus

Post. Colliculus

[L] “Little hill”

Talus

http://www.schreibman.info/




http://www.mr-d-n-t.co.uk/wood-joints.htm

https://en.wikipedia.org/?title=Stonehenge




http://www.ncbi.nlm.nih.gov/pubmed/20194311

http://www.ncbi.nlm.nih.gov/pubmed/22298056


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3228707/pdf/1471-2474-12-253.pdf

http://www.cdc.gov/ncbddd/jointrom/









7/52

Radiographs well show malleoli

G,J 47yoM

AP view Lateral viewMortise view

Internally rotated15-20°

MMLM

PM

AP view doesn’t profile

the mortise

Mortise view DOES profile the mortise

Medial clear space

Lateralclear space

Look through Tibia to see Fibula on

lateral view!

ov erlap

Most of the fractures in this lecture are best shown via the Mortise view

Sometimes the best view of the Fibula fracture is on the Lateral,

through the Tibia






8/52

Ankle Joint is a lot like the WristTibia

Fibula

Radius

Ulna

Proximal ½ has 2 long bones:Tibia &Fibula

Radius & Ulna

Primary Joint:Ankle Mortise

Radial-Carpal

Secondary Jt:Distal Radio-Ulna Jt

Syndesmosis

DRUJRCJ

Mortise

Syndesmosis






9/52

Syndesmosis

Incisura: [L] “notch”Fibula sits in Tibial Incisura

on all viewsYou should not see

much of a gap between tibia/fibula on any view

Ligamentous JointNot synovial jointUnlike most other joints

Ant & Post Tib/Fib lig.“Syndesmotic ligaments

Tibia

Fibula

SyndesmosisAnterior v iew

Bottom-Up v iew

Top-dow nv iew

:[Gr]

Axial T12

σύν “with”, δεσμός “ligament”

Ant TFL

Post TFL






10/52

The Ankle is a Very Stable JointTibia

Fibula

Talus

Talo-Fib

Deltoid

Tib-Fib

aofas.org

Tibia-Fibula ligaments (Ant&Post)Stabilize the syndesmosis

Talo-Fibula ligaments (Ant&Post)Stabilize the lateral clear space

Deltoid ligament (Superficial&Deep)Stabilizes the medial clear spaceThese allow very little normal inversion/eversion of ankle jointTwisting forces can tear ligs.Tibiofibular = “High ankle sprain”Talofibular = “Ankle sprain”Excessive forces can Fxs.






11/52

Inversion/EversionAnkle Fx Classification:My overly simplified system

Talus

Tibia

Fibula

Talus

Tibia

Fibula

Tibia

Fibula

InversionAvulsionon Lateral Malleolus± Medial Malleolar Fx:

Compression Fx

Tibia

Fibula

EversionCompressionon Lateral Malleolus± Medial Malleolar Fx:

Avulsion Fx

Understanding Fxs:Avulsion Fxs: Horizontal

Compression Fxs: Vertical

In both of these:FIBULA FRACTURES

(Fibula smaller than Tibia)

Opposite Forces Opposite Fractures

Is Syndesmosisat risk?

Not at risk At Risk






12/52

Ankle Fx Classification:

AbductionAdduction

Ankle Fx Classification: Lauge-Hansen

RadioGraphics 2000; 20:819–836

External rotation

Pronated foot

Rockwood & Green’s Fractures in Adults8th Ed. ©2015 [Kindle Edition] Fig. 59-8

Supinated foot

External rotation

Niel Lauge-Hansen (1899–1976)

Prominent Danish phy sician Used cadav ers to elucidate

mechanisms of ankle injuries Based on foot POSITION

at time of injurySupinationPronation

and DIRECTION of forcesAdductionAbductionExternal rotation

Arch Surg. 1950;60:957–985

I don’t know anyone who uses this system





https://www.aofas.org/footcaremd/conditions/ailments-of-the-ankle/Pages/Ankle-Sprain-.aspx










13/52

AO* Classification

w ww.aofoundation.org/Documents/mueller_ao_class.pdf

ALL fractures can classifiedPrimarily as A, B, CSecondarily as 1, 2, 3

“Proximal Tib ial Fractures”

“Distal Tib ial Fractures”

C1 C2 C3

C1 C2 C3

B1 B2 B3

B1 B2 B3

A1 A2 A3

A1 A2 A3

*Arbeitsgemeinschaft für Osteosynthesefragen“Association for the Study of Internal Fixation”






14/52

Ankle Fx Classification: WeberBernhard Georg (Hardi) Weber (1927–2002)

Swiss surgeon, early member of the AOClassified ankle fractures into 3 typesA, B, C (Just like all AO fractures)Based upon level of Fibular Fracture

relative to the Syndesmosis

©1966The injuries of the upper ankle

Type AFibulaläsion distal der Syndesmose

“ Infra-sy ndesmotic”

Syndes: INTACT

Fibula: HorizontalAv ulsion Fx

Type CFibulaläsion proximal

der Syndesmose

“Supra-sy ndesmotic”

Syndes: TORN!

Fibula: VerticalCompression Fx

Type BFibulaläsion in der

Höhe der Syndesmose

“Trans-syndesmotic”

Syndes: AT RISK

Fibula: VerticalCompression Fx

pages52-56






15/52

Ankle Fx Classification: Weber A

Tibia

FibulaNot at r isk

G,R 49yoF

Lat MalleolusAvulsion fracture

SyndesIntact

B,C 17yoF

LMAvul Fx

MM Comp Fx

SyndesIntact

AO: Type A1“Uni-Malleolar Fx”

AO: Type A2“Bi-Malleolar Fx”

AO: Type A3“Tri-MalleolarFx”

Rare (1%)I don’t have any

Infra-syndesmotic






16/52

Tibia

FibulaAt Risk

Fibula MetaphysisCompression Fracture

Ankle Fx Classification: Weber B

P,A 20yoM

SyndesIntact

Trans-syndesmotic

AO: Type B1“Uni-Malleolar Fx”

A,C 54yoF


SyndesIntact

MMAvulFx

AO: Type B2“Bi-Malleolar Fx”


Z,C 68yoF

MMAvulFx

SyndesIntact

Lateral view

AO: Type B3“Tri-Malleolar Fx”

Fib Fx

PM Fx






17/52

Tibia

FibulaDisrupted

Supra-syndesmotic

No

C: Fib Shaft Fx = Syndesmosis DisruptedC1: Simple

Fibula Fx

Ankle Fx Classification: Weber C

G,R 72yoM

Syndesappears

intact

MCS not Wide

MCSWidens

SyndesWidens

No

MCSWidens

SyndesWidens

Intra-Op

Stress

S,O 68yoM

C2: ComminutedFibula Fx

Pre-cast

Tibia

Post-cast

Talus

Tibia

Post-RE-castingPost-Operative

P,H 42yoF

C3: ProximalFibula Fx

MCSWide

SyndesWide

Sometimes Fib Fx so proximal it’s not included on the Ankle

views…

Look Higher Need Tib/Fib views!

“Maisonneuve”ORIFFib

Plate

Syndes-moticScrew

2 Syndes-motic

Screws

or






18/52

Based upon level of Fibula FractureA: Infra-syndesmotic

Due to talus Inversion Avulsion Fx

B: Trans-syndesmoticDue to talus Eversion Compression Fx

C: Supra-syndesmoticDue to talus Eversion Compression Fx

C1 C2 C3

Ankle Fx Classification: WeberAnkle Fx Classification: Weber AO

w ww2.aofoundation.org

A

B

C

A1 A2 A3

B1 B2 B3

Complex Slide Warning

Acta Orthop. 1998;69:43–471,500 fx s in a 3 y ear period

38%

52%

10%

25% 12% 1%

27% 15% 10%

5% 4% 1%

Fib only + MM + PM

Simple ComminutedMaisonneuve


https://www.aofoundation.org/Documents/mueller_ao_class.pdf






https://www2.aofoundation.org/wps/portal/surgery








19/52

Need Both AP & Mortise Views

T,S 61yoMMerrill's Atlas of Radiographic Positioning and Procedures 12 Ed. Vol. 1 ©2012 [Print Replica] [Kindle Edition] Fig. 6-103

AP view Mortise view AP view Mortise view

Positioning for Mortise v iew

Positioning for AP v iew


?

All the fractures I’ve shown so far in this

presentation have been mortise views!

Type

B 1






20/52

Need AP, Mortise and Lateral Views!

T,L 17yoM

AP view Lateral viewMortise view

?

Wide medial clear space:Deltoid torn

?

?



through the Tibia

Type

B 1






21/52

Need AP, Mortise and Lateral Views!

H,J 24yoM

Lateral viewMortise view

LateralSoftTissueSwelling…

AP viewNo Fibula

Fx…

Clue to look

closer…

No Fibula Fx Fibula Fx


through the Tibia






22/52

Pt may c/o “Ankle Pain”not “Prox Fibula Pain”

Every Malleolar Fx, I ask:Is this Type A?No, A: LM Avul (Infra-sy ndesmotic)

Is this Type B?Where’s Fib fx? (Trans-sy ndesmotic)CHECK LATERAL VIEW!

Is this Type C?Where’s Fib fx?(Supra-sy ndesmotic)Tib/Fib VIEW!

Shaft Fx = Sy ndes Disrupted!

Maisonneuve’s (C3) Can Be Tricky

W,R 30yoM

MMAvul

Fx

PostMallFx

MMAvul

Fx

StressIntra-Op

UnstableInjury… Syndes-

moticScrew






23/52

Syndesmotic Screw is UniqueHardware

1)Fibular Plate2)MM Screw/wireRigid fixationSolid bony union3) Syndesmotic screwStabilize Tib/Fib jt.Allow torn Tib/Fib lig.

to form scar tissueThere’s not much difference between ligament&scar tissue

Don’t want bony unionExpect joint to moveExpect screw move

P,M 18yoFIn ER

AP Mortise

MMAvul

Fib ShaftFx

SyndesWide

Syndesappears intact

You should NOTsee gap between

Tibia/Fibula Post-Op(same day)

1

23

Fib Shaft Fx=Syndes

Disrupted MortiseSyndesmosisFibula FxsWeber ABC





24/52

OK for syndesmotic screws to loosen

P,M 18yoFPost-Op… 6 months later

Fib Shaft Fx… Healed

MM Fx

Healed

Expect syndesmotic screw to move

“Windshield Wiper”

hilariousgifs.comThis is my favorite slide…

2007 GIF


http://www.amazon.com/Merrills-Atlas-Radiographic-Positioning-Procedures-ebook/dp/B00EJXYNUC/ref=sr_1_5_bnp_1_kin?ie=UTF8&qid=1413041504&sr=8-5&keywords=merrills+atlas+of+radiographic+positioning+and+procedures+12th+edition






http://www.hilariousgifs.com/just-a-bird-on-a-windshield-wiper/








25/52

AP Oblique

Radiographs well show T-MT Joint

K,R 20yoM

II

2

II

2

Standing AP

shows alignment medial 2nd T-MT

Standing Obl

shows alignment lateral 2nd T-MT

II

2

III

3

Normal FacetsMT2 - MT3MT2 - Cune III






26/52

AP

How we shoot AP/Obl Foot Radiographs

StandingAP

StandingOblique

StandingAP

Marty18yoM

X-ray cassette on floor

Vertical x-ray beam

X-raytube

nearlyVertical

x-ray beam

X-raytube

30°

Oblique






27/52

How we shoot Lateral Foot RadiographsShooting standing lateral foot presents a challengeX-ray tube can’t be lowered

all the way down to the floor

Patient stands on raised two step platformX-ray cassette sandwiched

between the feetHorizontal X-ray beam

X-raytube

X-raycassette






28/52

How we shoot Lateral Foot RadiographsStanding

Lateral

Notice the top step is in the X-ray field of view






29/52

Can always tell if standing…1) Technologist should indicate

this on the imageWith text,or an Up arrow

2) On lateral, can see the step the patient is standing onSometimes can even see the

screws holding steps together

G,J 19yoF






30/52

Foot Radiographs SHOULD be Standing

M,D 29yoM

If patient walked into the clinic,can stand for foot radiographs

StandingOblique

Fx

Fx

StandingLateral














31/52

Lisfranc Joint

AnatomicAlignmentMT1:Cuneiform IMT2:Cuneiform IIMT3:Cuneiform IIIMT4&5:Cuboid

12 3

45

Metatarsal Bases

MT2 Basesticks down

like a Keystone

Key stone

…locking the entireT-MT joint in place

45

Cu

1

I2

II

3

III

“a large stone at the top of an arch that locks the other stones in place”

Keystone

All 5 Metatarsals are tied together as a unit…






32/52

Lisfranc Fracture/Dislocations

Cu

III III

12 3

45

S,T 34yoFAP

I

1

II

2

III

34

5

Cu

III III

12 3

45

M,D3-D CT

One Pattern: HomolateralAll 5 MTs dislocate laterally as a unit

None of the MTs are aligned with the

cuneiforms/cuboid






33/52

Lisfranc Ligament

ConnectsLateral side of

Cuneiform IMedial Base of

MT2

45

Cu

1

I2

II

3

III

AJR Online 2010; 195:W447–W455

Photograph of gross anatomic

section

MR long axisPD

MR long axisFatSat PD

Dislocations of the Lisfranc joint typically fracture the 2nd Metatarsal Base,

may present as avulsion fractures off the Medial Base of the 2nd MT!






34/52

Lisfranc Fracture/Dislocations

Cu

III III

12 3

45

Another Pattern: DivergentMTs 2-5 dislocate laterally as a unit,

Divergent from MT1

H,D 82yoMAP Obl

I

1

I

1

II

2

III

34

5

Fx Med Base MT2 Fx Med Base MT2

Cu

III III

12 3

45

Fx Med Base MT2

1st T-MT: Aligned

2-5 T-MTs: Dislocated






35/52

Lisfranc Fracture/Dislocations can be subtle!Anatomic Alignment

1st T-MT

2nd T-MT

Lateral Offset

1st T-MT

2nd T-MT

S,J 27yoMAP Standing AP Standing

SymptomaticAsymptomatic

Standing AP:Alignment medial 1st & 2nd T-MT

DiastasisMT1-MT2

Normal SpaceMT1-MT2






36/52

Lisfranc Fracture Classification

Nonathletic Lisfranc injuriesResult of high-velocity force (MVC)

Athletic Lisfranc injuriesResult of low-velocity indirect force

Second most common foot injury4% of football players/year29% occurring in offensive l ine

Diastasis between MT1-MT2Weightbearing radiographsComparison with normal side

Nunley & Vertullo. Midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med. 2002;30(6): 871-878

RecentStage 1

Lisfrancligamentsprain

Nodiastasis

Stages 2 & 3Lisfrancligamentrupture

2:1-5mmdiastasis

3:>5mm diastasis

Lisfranc Injuries in the Athlete


http://publicsource.org/projects/under-the-keystone



http://www.ajronline.org/doi/pdf/10.2214/AJR.10.4674




http://ajs.sagepub.com.ezproxy.library.wisc.edu/content/30/6/871.full.pdf+html








37/52

19th Century1800 1900

1895Röntgen

A new type of radiation

1909Quéne & Küss

1st Lisfranc Radiographic classification

Roentgen’s original paperRobert William Smith p227

1847Smith describes

T-MT dislocation

1790-1847Jacques Lisfranc

de St. Martinnever described

the fracture, the dislocation,or the ligament

that carry his name

Timeline: Lisfranc Fracture

www.biusante.parisdescartes.fr






38/52


Timeline:

books.google.com

1815Lisfranc

“New method for partial foot amputation of

tarso-metatarsal joint”50 pages

B,T 53yoMPlantar ulcer

Lisfranc Amputation






39/52


Timeline: Lisfranc – Prolific WriterDescribed many new surgical procedures1815: T-MT joint amputation1815: Glenohumeral jt. amputation

1823: Hip joint amputation1824: Excision cancerous rectum1836: “Diseases of the uterus,

according to clinical lessons”Pioneer in extirpation of the cervix

www.biusante.parisdescartes.fr w honamedit.com






40/52


Timeline: Lisfranc – Battlefield Surgeon

1803–1815Napoleonic Wars

Described many new surgical procedures1815: T-MT joint amputation1815: Glenohumeral jt. amputation

For a short time active as an army surgeon - Médecin-adjoint1813: Obtained Medical Degree

(age 23)1814: left the army

w honamedit.comUne histoire de la Médecine






41/52


Timeline: Lisfranc – Pre-Ether Surgeon

1803–1815Napoleonic Wars

1815: T-MT joint amputationLisfranc was well known for his ability

to amputate a foot in less than 1 minuteClin Podiatr Med Surg22 (2005) 385– 3931st Use Ether Anesthetic

1846

nejm.org






42/52

Lisfranc’s Tomb

napoleon-monuments.eu

Le magnifique bas-relief en bronze


http://www.jstor.org/stable/225483?seq=1#page_scan_tab_contents

http://www.christies.com/lotfinder/books-manuscripts/rontgen-wilhelm-conrad-ueber-eine-neue-5084328-details.aspx

https://archive.org/details/treatiseonfractu1847smit

http://www2.biusante.parisdescartes.fr/img/?refbiogr=9991&mod=s


http://google.com/books?id=Hw1bAAAAQAAJ

http://www.jstor.org/stable/225483?seq=1#page_scan_tab_contents


http://www2.biusante.parisdescartes.fr/img/?refbiogr=9991&mod=s

http://www.whonamedit.com/person_bibliography/2572/


http://www.whonamedit.com/person_bibliography/2572/

http://www.homeoint.org/articles/daucourt/empire.htm


http://www.sciencedirect.com/science/article/pii/S0891842205000285

http://blogs.nejm.org/now/index.php/the-most-important-article-in-nejm-history/2012/11/01/


http://napoleon-monuments.eu/ACMN/Lisfranc.htm








43/52

N Cu

III III

12 3

4

Ta Ca

Forefoot (white)5 MetatarsalsPhalanges

Lisfranc Joint(Tarsal-Metatarsal Joint)

Midfoot (blue-green)

NavicularCuboid3 Cuneiforms

Chopart Joint

Hindfoot (yellow)TalusCalcaneus

Anatomic Divisions5th is most commonly fractured metatarsal5th MT fxs account for

2/3 all MT fxs

3 ProximalFractureZones

Rockw ood & Green’s Fractures in Adults8th Ed. ©2015 [Kindle Edition] Loc.101734

5

5th MT: Fractures5th MT:

BaseIntra-

Articular“Avulsion Fxs”93%

I

II Prox Metaphysis“Jones Fx” (4%)

III Prox Shaft“Stress Fx” (3%)

Distal Shaft“Dancer’s Fx”Spiral Fx






44/52

View from

above

Apophysis is longitudinally oriented

5th MT fxs are transversely orientedView

from below

CuboidArticulation

5th MT: Base

Cu

=Fused ApophysisB,B 13yoM

Obl

Rigid flatfootCa

N Tarsal Coalition

Tuberosity

MT heads=Epiphyses(Part of a joint)

Transverse PhysesTuberosity (Tendon insert)=ApophysisLongitude Physis






45/52

5th MT: Base AttachmentsPeroneal BrevisUnder Fibula

Plantar Fascia Lateral Band

Not Peroneal LongusUnder Fibula (with PB)Under Cuboid Peroneal Sulcus Inserts base 1st T-MT~20% have Os Peroneum May be bipartite

Cu

T,A 35yoF

Bipartite OsPeroneum

Per.Sulcus

OP

OP






46/52

5th MT: Base Fracture = AvulsionPeroneal BrevisPlantar FasciaTwisting MechanismSudden hindfoot inversion

weight on lateral 5th MTTension on PB & fasciaAvulsion fx

Transversely orientedIntra-ArticularHeal quickly & well

*100 Avulsion FracturesTreated conservatively99% healed clinically at 3w

radiographically at 8w

T,A 35yoF*Dameron. J Bone Joint Surg Am.1975;57(6):788-792

Tw isted foot instiletto heels

Initial Injury3 w eeks 6 w eeks 10 w eeks






47/52

5th MT: Prox Metaph Fx = JonesAcute InjuryForefoot adductionTension of 5th MT

lateral cortexFx: Metaph-Diaph Junction

Transversely orientedExtra-ArticularPoor, delayed healing

*Jones fx: 43 young athletes(16-22yo)

Half required surgery to achieve union

The rest achieved union only after 7-15m immobilization

Poor healing due to relative hypovascularity of proximal metaphysis 5th MT

M,J 24yoF*Torg, Pav lov. J Bone Joint Surg Am.

1984;66:209Courtesy of Helene Pav lovHosp Special Surgery, NY

Ink injectioncadaver 5th

metatarsal

No bloodsupply






48/52

5th MT Fxs: Lateral Ankle PainPatients with 5th MT fractures may complain of “Lateral Ankle Pain” rather than “5th MT Pain”Of course pt will be tender to palpation at 5th MTPCPs should ALWAYS examine pt before imaging

Techs: Need to include 5th MT on ankle radiographs!

Patient twisted ankle, lateral ankle pain.She called PCP, who called in request for ankle radiographs, without an exam.I saw no ankle fracture, but because my technologist included 5th MT…C,B 51yoF

Distal shaft spiral dancer’s fracture














49/52

5th MT Fxs: Lateral Ankle Pain

B,T 38yoM, complaining ofRight lateral ankle pain

MortiseAP Lateral MortiseSyndesmosisFibula FxsWeber ABC





50/52

Jones Fxs: Delayed Healing (7-15m)

B,T 38yoM, complaining ofRight lateral ankle pain

Initial

1 month:not healed

2 months:not healed

3 months:not healed

4 months:not healed

6 months:healing…

7 months:Healed!






51/52

Jones Fxs: Screw Fixation

B,T 39yoM, complaining ofLeft lateral ankle pain

“Screw it”






52/52

Jones Fxs: Need All 3 Foot Views

G,J 59yoF

Obl Standing Lateral StandingAP Standing

Can’t see the fracture

Fx

Fx






53/52

To get a better understandingof 3 common

eponymic fractures

Weber (AO)@Ankle Joint

Lisfranc@T-MT Joint

Jones@5th MT

Ankle MortiseAnatomyFracture Patterns

T-MT JointFx/Disloc PatternsHow not to miss

5th MTAvulsion FractureJones Fracturec/o Ankle Pain

Goal Objectives

www.schreibman.info Ken Schreibman, PhD/MD Professor of RadiologyUniversity of Wisconsin – Madison






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Any Questions About The Ankle?Turn Our Attention To The FootImportant Imaging DistinctionMR(CT) of the “Foot” covers

Midfoot Forefoot

MR(CT) of the “Ankle” covers Hindfoot Midfoot

I suggest consult radiologist before ordering both!

I INSIST you get radiographs before ordering any CT/MR!

Anatomic Divisions

Forefoot (white)5 MetatarsalsPhalanges

Lisfranc Joint(Tarsal-Metatarsal Joint)

Midfoot (blue-green)

NavicularCuboid3 Cuneiforms

N Cu

III III

12 3 4

5

Chopart JointHindfoot (yellow)TalusCalcaneus

Ta Ca

Anatomic Alignment

TransitionSlide















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(1885-1935)

first printed 1934

Father of Orthopedic Surgery?Othropædicfrom Greekorthostraight, correct

pedochild

“to straighten children”

Sir Robert Jones:

amazon.com

Jones’ son-in-law

Bonus1/17






56/52Bonus2/17

Favorite son of Rhyl, WalesSir Robert Jones:

Plaque in Rhy l Library(behind microfilm viewer)

UK

Wales

Rhyl

age 5 (1862)Jones family moved to London

age 16 (1873)Robert moved to Liverpool with Uncle Hugh Owen ThomasLiverpool School of Medicine

age 21 (1878)Apprenticed with HO Thomas






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Apprenticed with HO Thomas

Plaque in Rhy l Library (behind microfilm viewer)

Sir Robert Jones:

Rhyl






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Hugh Owen Thomas: Father of Orthopedic Surgery

(23 August 1834 – 1891)

Son of famous Liverpool bonesetter1855: Attended Edinburgh University1858: Medical Register considered

bonesetters “unqualified”1857: Qualified as MRCS

Goes into practice with father1859: Set up own practice in

poorer part of LiverpoolCholera, TB rampant among poorThomas made daily house-callsRan a free clinic on SundaysHad no hospital admitting privileges

Thomas Splint

Anglesey Bonesetters alpacas.au

w ellcomeimages.org






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Hugh Owen Thomas: Father of OrthoticsHad his own shop to make customized braces

w ellcomeimages.orgHugh Ow en Thomas: the cripple's champion

Bonus5/17






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Hugh Owen Thomas: Champion of the PoorTuberculosis largely disease of the poorChildren largely a disease of joints (hip, spine)1843:Dickens “A Christmas Carol”1846:Ether used for surgical anesthesia1867:Lister introduces antiseptic surgical techniquesLate 1880s:Aseptic surgical techniques employedSurgery becomes popular to treat infected jointsearly excision of the joint limb amputation

It was particularly the working class children who underwent this type of aggressive surgery

The wealthy instead got longterm convalescence

2012 CTM A Christmas Carol


http://www.amazon.com/life-Sir-Robert-Jones/dp/B0006AMQ1A/


https://rhylhistoryclub.wordpress.com/category/sir-robert-jones/




http://www.ganapathihipkneesurgeon.com/anglesey bonesetters and modern orthopaedics.html

http://auravalealpacas.com.au/archives/802

http://wellcomeimages.org/


http://wellcomeimages.org/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1676236/


http://host.madison.com/ctm-a-christmas-carol-tiny-tim-and-scrooge/image_22cde0b8-46ce-11e2-93a2-001a4bcf887a.html








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Hugh Owen Thomas: Champion of the PoorSurgery becomes popular to treat infected jointsParticularly for working class childrenearly excision of the joint limb amputation

Child amputees outside a "crippleage”

Thomas hated these crippling operations.

Instead, he prescribed immobilization & rest"enforced, uninterrupted

and prolonged“

Healing powersof fresh air






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Hugh Owen Thomas: Champion of fresh air

Rhyl Sea Side Hospital and Convalescent Home

Suntanned children on Thomas frames, Woodlands Hospital, Birmingham, 1927






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Hugh Owen Thomas: Father of Orthopedic SurgeryNephew of Orthopedic SurgerySir Robert Jones:

Thomas’s patients came mostly from nearby docks, sailors w ith fractures and dislocations untreated for w eeks or month.Thomas treated these injuries using the traditional skills of his ancestors – recruiting assistance of labourers from the street.

Hugh Owen Thomas

Shoulderdislocation

Recruited

ApprenticeRobertJones

Hugh Ow en Thomas: the cripple's champion






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Disciple of Hugh Owen ThomasSadly, and largely for reasons of his own making, Thomas’s principles were not

widely accepted by the medical profession during his lifetime.

“One of the greatest things Robert Jones ever did was to make the main principles of Hugh Owen Thomas

acceptable to the medical profession”

Sir Robert Jones:

Hugh Ow en Thomas: the cripple's champion






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World War I & Thomas SplintRevolutionized wounded soldier care at the battlefrontUse of Thomas splint for femur fractures

Reduced open femur fracture mortality from 87% to less than 8%*

Sir Robert Jones:

1894 Joined Volunteers asMedical Officer to submarine miners

1916 (age 59): Appointed Inspector of Military Orthopaedics

1917 KnightedThomas splint, Broussey France, 1918

1917*Hugh Ow en Thomas: Medical Legacy






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Annals of Surgery Vol. XXXV, No. 6, 1902 p.697-700

Radiology PioneerSir Robert Jones:

Wikipedia

1895: Röntgen “A new type of radiation”1896: Jones “The discovery of a bullet lost in wrist by means of Roentgen rays”First published clinical use of x-rays1896: Jones fractures his foot

Lancet 1896 v 147 p477

Link to Jones’s Original Article











http://www.kumc.edu/wwi/index-of-essays/regimental-aid-station.html

http://www.loyalregiment.com/241633-pte-j-german-l-n-lan-r/

http://en.wikipedia.org/wiki/Hugh_Owen_Thomas


http://en.wikipedia.org/wiki/Robert_Jones_(surgeon)

http://www.grandroundsjournal.com/articles/gr14l002/jones.pdf









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“whilst dancing”Ex ample of the high spirits of the Volunteer mov ement:“In camp in 1896 we were all dancing in a circle round the tentpole singing ‘Solomon Levi’.(1890 square dance)Robert Jones’ ankle seemed to give…he said he had strained such and such a muscle or tendon, exclaiming:

‘Most interesting, most painful. I had no idea it could be so painful. Most interesting!’

“At that time he (Jones) had what might almost be described as a new toy –an X-ray apparatus, the first in England. “He wondered whether it would not be possible for the X-ray to show the torn or swollen muscle (peroneus longus), and on experimenting the plate showed to his amazement that a small bone was fractured. (5th metatarsal)“It was understood that this particular bone could not be broken by a slight turning of the ankle, but here was a case where it had happened.“Jones immediately thought of several patients of his, whom he had treated for similar strain, and asked them to oblige him by coming to be X-rayed”.

Sir Robert Jones:

The Life of Sir Robert Jones, by Frederick WatsonFirst printed 1934 [Av ailable at Amazon.com] p98

Ex ample of 1896 tent

Bonus13/17






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The Jones FractureSir Robert Jones: Case 1. RJ 39yo Physiciantrod on outer side of foot,whilst dancing

Case 2. 30yoM inverted foot stepping on stone, whilst fishing

Case 3. 54yoM Inverted footrunning for train

Case 4. 50yoM Inverted footwalking up plank

“To one patient who came with mysterious symptoms he said, after a brief examination,‘Madam, you could have paid me no greater compliment

– this is a genuine Jones fracture.’”

?!

! !

Now, it is obvious that this fracture is very common, otherwise one would not be able to meet so many cases in so short a time.

There is, however, no referenceto it in surgical literature.

Annals of Surgery Vol. XXXV, No. 6, 1902 p.697-700

Bonus14/17






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Radiology Champion“Radiography here, as in all branches of medicine, is an essential aid to diagnosis. No matter how experienced we may be, we cannot afford to dispense with it, even in the apparently simple and obvious case.

Not only should we insist upon procuring a film, but it is equally important that we should welcome the radiologist’s reading of it. Some surgeons resent this and say, ‘Give me the film so that I can read it myself,’…

…but this is an arrogant and stupid attitude, and not the patient’s advantage.”

Sir Robert Jones:

Jones R. “Manipulation as a Therapeutic Measure”Proc. R. Soc. Med. 1932 25 (9) p.1406

Bonus15/17






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Champion of Crippled Children

Cr itical analysis of the poor care of crippled childr en throughout England.

Pr oposed a scheme to deal with shortcomings.

This publication resulted in the founding of the Centr al Council for the Car e of Cr ipples,built homes that housed cr ippled children, equipped with oper ating rooms, gymnasiums, schoolr ooms, and play r ooms.

1935: England had a total of 6000 or thopaedic beds and 400 or thopaedic clinics.

Sir Robert Jones:

Br Med J. 1919 Oct 11; 2(3067): 457–460

“Keeping Up With The Joneses”—The Story ofSir Robert Jones And Sir Reginald Watson-jones

Bonus16/17






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InspirationScientific thinker, inventive craftsman, teacher, leader of men, he gave himself and through his disciples great service to mankind. For him the thread of life was ‘strung with the beads of thought and love’.

The Right Honourable Lord Dawson of Penn, P.C., G.C.V.O., President of the Royal College of Physicians, in Liverpool Cathedral. February 5th, 1933

The shining lustre of his name is an abiding glory of British Surgery: but it is the man himself whom his fellow countrymen will wish to hold in remembrance”.

From a leading article in “ The Times” , October 14th, 1933

Sir Robert Jones:

Rhy l History Club Bonus17/17






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Any Questions?

123rf.com


http://www.amazon.com/life-Sir-Robert-Jones/dp/B0006AMQ1A/

http://www.flickriver.com/photos/uon/3307234489/




http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2184044/pdf/procrsmed00798-0056.pdf







http://www.123rf.com/photo_13502617_foot-print-in-the-form-of-a-question-mark-on-white-backgroud.html